Behavior Therapy

Behavioral strategies to
reinforce changes in diet and physical activity can produce a weight loss in
obese adults in the range of 10 percent of baseline weight over 4 months to 1
year. Unless a patient acquires a new set of eating and physical activity
habits, long-term weight reduction is unlikely to succeed. The acquisition of
new habits is particularly important for long-term weight maintenance at a
lower weight. Most patients return to baseline weights in the absence of
continued intervention. Thus, the physician or staff members must become
familiar with techniques for modifying life habits of overweight or obese
patients.

The goal of behavior therapy
is to alter the eating and activity habits of an obese patient. Techniques for
behavior therapy have been developed to assist patients in modifying their life
habits.

Evidence Statement:
Behavior therapy, in combination with an energy deficit, provides
additional benefits in assisting patients to lose weight short-term (1 year).
Its effectiveness for long-term weight maintenance has not been shown in the
absence of continued behavioral intervention. Evidence Category B.

Rationale: The primary
assumptions of behavior therapy are that:

by changing eating and
physical activity habits, it is possible to change body weight;

patterns of eating and
physical activity are learned behaviors and can be modified; and

to change these patterns
over the long term, the environment must be changed.

Behavior therapies provide
methods for overcoming barriers to compliance with dietary therapy and/or
increased physical activity, and are thus important components of weight loss
therapy. Most weight loss programs incorporating behavioral strategies do so as
a package that includes education about nutrition and physical activity.
However, this standard "package" of management should not ignore the
need for individualizing behavioral strategies (579).

Studies reviewed for this
report examined a range of modalities of behavioral therapy. No single method
or combination of behavioral methods proved to be clearly superior. Thus,
various strategies can be used by the practitioner to modify patient behavior.
The aim is to change eating and physical activity behaviors over the long term.
Such change can be achieved either on an individual basis or in group settings.
Group therapy has the advantage of lower cost. Specific behavioral strategies
include the following:

Self-monitoring of both
eating habits and physical activityObjectifying one's own behavior
through observation and recording is a key step in behavior therapy. Patients
should be taught to record the amount and types of food they eat, the caloric
values, and nutrient composition. Keeping a record of the frequency, intensity,
and type of physical activity likewise will add insight to personal behavior.
Extending records to time, place, and feelings related to eating and physical
activity will help to bring previously unrecognized behavior to light (580).

Stress
managementStress can trigger dysfunctional eating patterns, and
stress management can defuse situations leading to overeating. Coping
strategies, meditation, and relaxation techniques all have been successfully
employed to reduce stress.

Stimulus
controlIdentifying stimuli that may encourage incidental eating
enables individuals to limit their exposure to high-risk situations. Examples
of stimulus control strategies include learning to shop carefully for healthy
foods, keeping high-calorie foods out of the house, limiting the times and
places of eating, and consciously avoiding situations in which overeating
occurs (580).

Problem
solvingThis term refers to the self-corrections of problem areas
related to eating and physical activity. Approaches to problem solving include
identifying weight-related problems, generating or brainstorming possible
solutions and choosing one, planning and implementing the healthier
alternative, and evaluating the outcome of possible changes in behavior (580). Patients should be encouraged to
reevaluate setbacks in behavior and to ask "What did I learn from this
attempt?" rather than punishing themselves.

Contingency
managementBehavior can be changed by use of rewards for specific
actions, such as increasing time spent walking or reducing consumption of
specific foods (44). Verbal as well as
tangible rewards can be useful, particularly for adults. Rewards can come from
either the professional team or from the patients themselves. For example,
self-rewards can be monetary or social and should be encouraged.

Cognitive
restructuringUnrealistic goals and inaccurate beliefs about weight
loss and body image need to be modified to help change self-defeating thoughts
and feelings that undermine weight loss efforts. Rational responses designed to
replace negative thoughts are encouraged (580). For example, the thought, "I
blew my diet this morning by eating that doughnut; I may as well eat what I
like for the rest of the day," could be replaced by a more adaptive
thought, such as, "Well, I ate the doughnut this morning, but I can still
eat in a healthy manner at lunch and dinner."

Social
supportA strong system of social support can facilitate weight
reduction. Family members, friends, or colleagues can assist an individual in
maintaining motivation and providing positive reinforcement. Some patients may
benefit by entering a weight reduction support group. Overweight patients
should be asked about (possibly) overweight children and family weight control
strategies. Parents and children should work together to engage in and maintain
healthy dietary and physical activity habits.

Treatment
of obese individuals with binge eating disorder

If a patient suffers from
binge eating disorder (BED), consideration can be given to referring the
patient to a health professional who specializes in BED treatment. Behavioral
approaches to BED associated with obesity have been derived from cognitive
behavior therapy (CBT) used to treat bulimia nervosa (227). Among the techniques are
self-monitoring of eating patterns, encouraging regular patterns of eating
(three meals a day plus planned snacks), cognitive restructuring, and relapse
prevention strategies (581).

Recommendation: Behavioral therapy strategies to promote
diet and physical activity should be used routinely, as they are helpful in
achieving weight loss and weight maintenance. Evidence Category B.